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Patients with rectovaginal fistulas have a significantly reduced quality of life. Therefore, surgical therapy is often needed even in palliative cases. The aim of the present study was to perform an analysis of the results of the different treatment options available today. We performed a retrospective analysis of patients who underwent treatment for rectovaginal fistulas at the Department of Surgery, University of Schleswig–Holstein, Campus Luebeck and the Department of Surgery, WKK Heide, between January 2000 and September 2016. Complication and recurrence rate were retrospectively evaluated. The median follow-up period was 13 months (range 3–36 months). During the observation period, 58 patients underwent surgery (53 curative, 5 palliative) for rectovaginal fistulas. All patients who underwent curative surgery had an omentoplasty, and 39 of 53 (73.6%) patients underwent a resection. Thirty of 39 (77.0%) resections were low anterior resection, while non-continence-preserving resection included subtotal colectomy (n = 5), pelvic exenteration (n = 2), and proctectomy (n = 2). The fistulas were mainly secondary to inflammatory bowel disease (n = 18) or diverticulitis (n = 13), while 19 fistulas were a complication of different cancers or precancerous lesions. The median follow-up time was 13 months (range 6–36). Four patients (6.9%) had fistula recurrence (3 recurrences after low anterior resection, 1 after primary fistula closure). The mortality rate was 6.9% (n = 4). Non-resecting methods should be used only in uncomplicated fistulas. Rectovaginal fistulas secondary to inflammatory or malignant disease mostly require extensive therapy. Omentoplasty is effective for the treatment of both high and low rectovaginal fistulas.

Laparoscopy for colorectal cancer resection bares early post-operative advantages and results in equal oncologic long-term outcome. However, data on laparoscopic right hemi-colectomy is scarce. Aim of the present study was to analyze a well selected collective of patients with right-sided colon cancer treated open and laparoscopically with regard to peri-operative and long-term outcome. We analyzed all patients who underwent right-sided hemi-colectomy for colon cancer between January 1996 and March 2013. Data was extracted from our prospective database. Inclusion criteria were tumor localization in the ascending colon, oncologic resection, histology of an adenocarcinoma, tumors UICC I–III, and R0 resection. Exclusion criteria were multiple malignancies including colon, emergency operation, adenoma or pT0 status, and UICC IV. For the matched pairs approach between patients undergoing laparoscopic (LAP) or open (OPEN) surgery, the parameters age, UICC stage, tumor grading, and sex were applied. A total of 188 patients was included in the analysis with n = 94 in both the LAP and the OPEN group. Some peri-operative results demonstrated advantages for laparoscopy including median return to liquid (p

The purpose of the present study was to investigate on the acceptance and frequency of laparoscopic surgery for the management of acute and chronic bowel obstruction in a general patient population in German hospitals. To receive an authoritative opinion on laparoscopic treatment of bowel obstruction in Germany, a cross-sectional online study was conducted. We designed an online-based survey, supported by the German College of Surgeons (Berufsverband der Deutschen Chirurgen, BDC) to get multi-institutional-based data from various level providers of patient care. Between January and February 2014, we received completed questionnaires from 235 individuals (16.7 %). The participating surgeons were a representative sample of German hospitals with regard to hospital size, level of center size, and localization. A total of 74.9 % (n = 176) of all responders stated to use laparoscopy as the initial step of exploration in expected bowel obstruction. This procedure was highly statistically associated with the frequency of overall laparoscopic interventions and laparoscopic experience. The overall conversion rate was reported to be 29.4 %. This survey, investigating on the use of laparoscopic exploration or interventions in bowel obstruction, was able to show that by now, a majority of the responding surgeons accept laparoscopy as an initial step for exploration of the abdomen in the case of bowel obstruction. Laparoscopy was considered to be at least comparable to open surgery in an emergency setting. Furthermore, data analysis demonstrated generally accepted advantages and disadvantages of the laparoscopic approach. Indications for or against laparoscopy are made after careful consideration in each individual case.

Background The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline. Methods An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference. Results Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery. Conclusions Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.

Background Postoperative surveillance after curative resection for colorectal cancer has been demostrated to improve survival. It remains unknown however, whether intensified surveillance provides a significant benefit regarding outcome and survival. This study was aimed at comparing different surveillance strategies regarding their effect on long-term outcome. Methods Between 1990 and 2006, all curative resections for colorectal cancer were selected from our prospective colorectal cancer database. All patients were offered to follow our institution's surveillance programm according to the ASCO guidelines. We defined surveillance as "intensive" in cases where > 70% appointments were attended and the program was completed. As "minimal" we defined surveillance with < 70% of the appointments attended and an incomplete program. As "none" we defined the group which did not take part in any surveillance. Results Out of 1469 patients 858 patients underwent "intensive", 297 "minimal" and 314 "none" surveillance. The three groups were well balanced regarding biographical data and tumor characteristics. The 5-year survival rates were 79% (intensive), 76% (minimal) and 54% (none) (OR 1.480, (95% CI 1.135-1.929); p < 0.0001), respectively. The 10-year survival rates were 65% (intensive), 50% (minimal) and 31% (none) (p < 0.0001), respectively. With a median follow-up of 70 months the median time of survival was 191 months (intensive), 116 months (minimal) and 66 months (none) (p < 0.0001). After recurrence, the 5-year survival rates were 32% (intensive, p = 0.034), 13% (minimal, p = 0.001) and 19% (none, p = 0.614). The median time of survival after recurrence was 31 months (intensive, p < 0.0001), 21 months (minimal, p < 0.0001) and 16 month (none, p < 0.0001) respectively. Conclusion Intensive surveillance after curative resection of colorectal cancer improves survival. In cases of recurrent disease, intensive surveillance has a positive impact on patients' prognosis. Large randomized, multicenter trials are needed to substantiate these results.

Background and aims Despite improved techniques, the determination of tumor origin in poorly differentiated adenocarcinomas still remains a challenge for the pathologist. Here we report the use of protein profiling combined with principal component analysis to improve diagnostic decision-making in tumor samples, in which standard pathologic investigations cannot present reliable results. Materials and methods A poorly differentiated adenocarcinoma of unknown origin located in the pelvis, infiltrating the sigmoid colon as well as the ovary, served as a model to evaluate our proteomic approach. Firstly, we characterized the protein expression profiles from eight advanced colon and seven ovarian adenocarcinomas using two-dimensional gel electrophoresis (2-DE). Qualitative and quantitative patterns were recorded and compared to the tumor of unknown origin. Based on these protein profiles, match sets from the different tumors were created. Finally, a multivariate principal component analysis was applied to the entire 2-DE data to disclose differences in protein patterns between the different tumors. Results Over 89% of the unknown tumor sample spots could be matched with the colon standard gel, whereas only 63% of the spots could be matched with the ovarian standard. In addition, principal component analysis impressively displayed the clustering of the unknown case within the colon cancer samples, whereas this case did not cluster at all within the group of ovarian adenocarcinomas. Conclusion These results show that 2-DE protein expression profiling combined with principal component analysis is a sensitive method for diagnosing undifferentiated adenocarcinomas of unknown origin. The described approach can contribute greatly to diagnostic decision-making and, with further technical improvements and a higher throughput, become a powerful tool in the armentarium of the pathologist.

The assessment of the quality of medical practice is a legitimate requirement by society. Reliable methods for measurement of the quality of performance are sought worldwide. Quality is often quantified by using administrative data and in Germany this method has been implemented by the health insurance company AOK.(1) How is the AOK quality system rated by senior consultant surgeons? (2) How valid are quality statements derived from administrative data?This article was compiled following the PRISMA (i.e. preferred reporting items for systematic reviews and meta-analyses) statement for qualitative systematic reviews. In order to answer the first question the Professional Association of German Surgeons (Berufsverband der Deutschen Chirurgen) initiated two surveys and to answer the second question a structured literature search following the PICO (i.e. patient problem or population, intervention, comparison control or comparator and outcomes) format was initiated. In addition numerous websites were contacted.Of the responding senior consultant surgeons 95% considered that the AOK method of quality measurement by administrative data is not objective. One third was definitely wrongly classified. The literature search revealed that no validation data exist for the AOK indicators, including the Elixhauser comorbidity risk score. Altogether, the sensitivity of indicators is poor when good sensitivity is defined by the Institute for Applied Quality Improvement and Research in Health Care (AQUA Institute) as ≥ 80 90%.Quality statements resulting from administrative data alone are unreliable.

In contrast to sigmoid diverticular disease, right colonic diverticulitis is a rare disease in Western countries. The clinical presentation is often similar to acute appendicitis. The aim of this study was to analyze surgical challenge in right-sided diverticulitis. All patients who underwent resection for both right-sided and sigmoid diverticular disease were registered prospectively in a database (observation period, 1996–2005). A retrospective analysis of all patients who underwent resection for right-sided colonic diverticulitis (ileocolic resection, right colectomy) was performed. Special focus was set on incidence, clinical symptoms, indication, procedure, clinical outcome, and histopathologic findings including immunohistochemistry. From a total of 593 patients treated surgically for recurring or acute complicated diverticular disease, the majority (97.8%) suffered from sigmoid diverticulitis (n = 580), whereas 2.2% (n = 16) underwent surgery for right-sided diverticulitis (including three patients with combined sigmoid and cecal diverticulitis). Related to the total number of appendectomies (n = 1167), this represented an incidence of 1.4%. In five of 16 patients, acute appendicitis was presumed preoperatively. Most common diagnostic was ultrasonography. In the group of patients with right-sided diverticulitis, the most common procedure was right hemicolectomy (n = 10), followed by ileocolic resection (n = 3) and combined right colonic resection with sigmoid resection (n = 3). Histopathological investigation confirmed complicated diverticulitis of the cecum with local perforation or abscess in 75% of the patients (12/16). Hypoganglionosis or aganglionosis was diagnosed in seven of the 16 resected specimens. As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis may be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis. As most cases will remain clinically unimminent, surgery is only indicated in complicated right-sided cases. Resection of the inflamed colonic segment with primary anastomosis is safe and can be performed laparoscopically. It can only be speculated whether hypoganglionosis or aganglionosis is a causative factor in the etiology of right-sided diverticulitis.

The aim of this study was to determine the prognostic role of matrix metalloproteinases in rectal cancer.Formalin-fixed and paraffin-embedded tissue sections of 94 rectal carcinomas were used for the immunohistochemical analysis of matrix metalloproteinases (MMP)-2, MMP-7, MT1-MMP, and tissue inhibitor of metalloproteinases (TIMP)-2. Inclusion criteria were sporadic rectal adenocarcinoma resected curatively (including total mesorectal excision), adjuvant radiochemotherapy in UICC stages II and III, and complete intra-institutional follow-up. Results of immunohistochemistry were correlated with clinical and histopathologic data from the prospective rectal cancer registry and prognosis. End points of the prognostic analysis were tumor progression caused by local and/or distant recurrence and 5-year survival (disease-free and overall). To assess prognostic significance, statistics included univariate and multivariate analysis (p0.05 statistically significant).Of the 94 rectal carcinomas, 35% (33/94) showed an epithelial MMP-2 expression, 77% (72/94) were MMP-2 positive in the stroma. Fifty-four percent (51/94) were MMP-7 positive, and 47% (46/94) were positive for both MT1-MMP and TIMP-2. The stromal MMP-2 staining pattern was correlated with the depth of invasion (pT status, p=0.006) with MMP-7 (p=0.016) and TIMP-2 expression (p=0.036). Positive expression of MMP-2 in tumor epithelium was correlated with MMP-7 (p=0.027), MT1-MMP (p=0.036), and TIMP-2 expression (p0.0001). A positive staining pattern of MMP-7 was significantly correlated with depth of invasion and TIMP-2 (p0.01). The positive staining pattern of MT1-MMP was correlated with epithelial MMP-2 (p=0.036), MMP-7 (p=0.004), and TIMP-2 expression (p=0.002). TIMP-2 immunoreactivity correlated with depth of invasion (p=0.013), epithelial MMP-2 (p0.001), stromal MMP-2 (p=0.036), MMP-7 (p0.001), and MT1-MMP (p=0.002). Neither pattern correlated with age, gender, tumor stage (UICC), grading, preoperative serum carcinoembryonic antigen (CEA) level, or nodal status (p0.05). Within a mean follow-up of 46 months, tumor progression, caused by either local recurrence or distant metastasis, occurred in 14 patients (15.4%). There was no significant association between the MMP expression and the incidence of local and/or distant recurrence. In terms of survival, preoperative CEA level (disease-free 5-year survival 46% with increased CEA vs 70% with normal CEA, p=0.01; overall 5-year survival 43 vs 74%, p0.01) and UICC stage were the only factors to be significantly related to 5-year survival by univariate analysis, whereas the metalloproteinases failed to show a significant association. In multivariate analysis, CEA and UICC stage were not identified as independent factors predictive of survival.MMP-2, MMP-7, MT1-MMP, and TIMP-2 do not appear to be significant predictors of prognosis in a homogenous collective of curatively resected rectal adenocarcinomas.

The aim of this study was to assess the results of laparoscopic stoma creation for fecal diversion, specifically focussing on feasibility, safety, and efficacy, as well as indications and techniques. Within a 10-year-period, all patients requiring laparoscopic stoma creation were evaluated prospectively. Patients’ profiles and indications, procedures and results of operation, conversion, morbidity, mortality and short-term complications (stoma-related, laparoscopy-associated) were analyzed. A total of 80 patients (39 males, 41 females) with a mean age of 55.5 years (range, 17–91) underwent laparoscopic stoma creation. Most common indications were unresectable advanced colorectal cancer (n=20), pelvic malignant cancer (e. g. ovarian, cervix and prostate cancer, n=16), and perianal Crohn’s disease with complex fistulas (n=16). Only in one female patient with pelvic malignant disease was the procedure converted to laparotomy due to obesity (conversion rate, 1.3%). 79 patients underwent laparoscopic stoma creation (completion rate, 98.7%) including loop ileostomy (n=30), loop sigmoid colostomy (n=40) and end sigmoid colostomy (n=9). Postoperative complications were documented in 9 patients (overall morbidity rate, 11.4%), including 4 minor complications treated conservatively (2 cases of prolonged atonia and 1 case each of pneumonia and urinary tract infection) and 5 major complications requiring reoperation (reoperation rate, 6.3%): one parastomal abscess (drainage), one stoma retraction following rod dislocation (laparoscopic stoma recreation), small bowel obstruction in two patients (small bowel resection), one port-site hernia (fascial closure), and hemorrhage (managed by re-laparoscopy). Mean operation time was 74 min (range, 30–245 min). Mean blood loss volume was 80 ml (range, 30–400 ml). Patients were discharged from hospital after a mean of 10.3 days (range, 3–47). Within a 1-year follow-up, no further stoma complications were documented. The advantages of laparoscopic stoma creation are low morbidity and reoperation rates, and no procedure-related mortality; our results suggest that laparoscopic stoma creation for fecal diversion is safe, feasible and effective. Therefore, at our institution, laparoscopic stoma creation is the method of choice for fecal diversion.

It was the aim of this prospective study to compare the outcome of laparoscopic sigmoid and anterior resection for diverticulitis and non-diverticular disease.All patients who underwent laparoscopic colectomy for benign and malignant disease within a 10-year period were entered into the prospective PC database registry. For outcome analysis, patients who underwent laparoscopic sigmoid and anterior resection for diverticular disease were compared with patients who underwent the same operation for non-inflammatory (non-diverticular) disease. The parameters analyzed included age, gender, co-morbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion, morbidity including major (requiring reoperation), minor (conservative treatment) and late-onset (postdischarge) complications, stay in the ICU, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Student's t-test and chi-square analysis (p0.05 was considered statistically significant).A total of 676 patients were evaluated including 363 with diverticular disease and 313 with non-inflammatory disease. There were no significant differences in conversion rates (6.6 vs. 7.3%, p0.05), so that the laparoscopic completion rate was 93.4% (n=339) in the diverticulitis group and 92.7% (n=290) in the non-diverticulitis group. The two groups did not differ significantly in age or presence of co-morbid conditions (p0.05). In the diverticulitis group, recurrent diverticulitis (58.4%), and complicated diverticulitis (27.7%) were the most common indications, whereas in the non-diverticulitis group, outlet obstruction by sigmoidoceles (30.0%) and cancer (32.4%) were the main indications. The most common procedure was laparoscopic sigmoid resection, followed by sigmoid resection with rectopexy and anterior resection. No significant differences were documented for major complications (7.4 vs. 7.9%), minor complications (11.5 vs. 14.5%), late-onset complications (3.0 vs. 3.5), reoperation (8.6 vs. 9.3%) or mortality (0.6 vs. 0.7%) between the two groups (p0.05). In the postoperative course, no differences were noted in terms of stay in the ICU, postoperative ileus, parenteral analgesics, oral feeding, and length of hospitalization (p0.05).These data indicate that laparoscopic sigmoid and anterior resection can be performed with acceptable morbidity and mortality for both diverticular disease and non-diverticular disease. The results show in particular that laparoscopic resection for inflammation is not associated with increased morbidity.

Thymidylate synthase (TS) and tumor suppressor p53 are two proteins with an influence on tumor resistance to radio-chemotherapy that is well known. For this reason we tested the effect of TS and p53 expression on clinical outcome (tumor recurrence and survival) in patients after curative tumor resection, especially in patients who received adjuvant radio-chemotherapy. A total of 120 patients with colorectal cancer were included in the study. A curative resection was possible in 83 patients, and 30 of this group received adjuvant therapy. For the immunohistochemical staining of tumor specimens, monoclonal antibody (mAb) TS 106 against TS and mAb DO-1 against p53 protein were used. TS positivity was defined as a moderate to high staining intensity in the cytoplasma of cells and p53 positivity as nuclear staining of tumor cells in >10% of these cells. Thymidylate synthase immunoreactivity was found in 59% of all cases and p53 staining in 51%. No relation between clinicopathological features and p53 expression was found in contrast to TS expression, where a highly significant association of TS-positive cases with tumor invasion (pT) was observed. Curatively resected patients with a TS-positive tumor developed tumor recurrence/distant metastases significantly more often than TS negative tumors. The same result was found when comparing p53-positive with p53-negative tumors and TS+/p53+ with TS−/p53− tumors. TS expression was highly significantly associated with poor survival and was the strongest independent prognostic factor in multivariate analysis, followed by lymph node status. Thymidylate synthase expression seems to be an independent prognostic factor and a possible predictor of tumor recurrence in patients with colorectal cancer.

Numerous surgical procedures have been suggested to treat rectal prolapse. In elderly and high-risk patients, perineal approaches such as Delorme's procedure and perineal rectosigmoidectomy (Altemeier's procedure) have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Functional results of transabdominal procedures, including mesh or suture rectopexy and resection-rectopexy, are thought to be associated with low recurrence rates and improved continence. Transabdominal procedures, however, usually imply rectal mobilization and fixation, colonic resection, or both, and some concern is voiced that morbidity, in terms of infection or leakage, and mortality could be increased. If we focus on surgical outcome, our own experience of laparoscopic resection-rectopexy for rectal prolapse shows that the laparoscopic approach is safe and effective, and functional results with respect to recurrence are favorable. However, the controversy "which operation is appropriate?" cannot be answered definitely, as a clear definition of rectal prolapse, the extent of a standardized diagnostic assessment, and the type of surgical procedure have not been identified in published series. Randomized trials are needed to improve the evidence with which the optimal surgical treatment of rectal prolapse can be defined.

Background. This study assessed the surgical concept and prognosis of perforated gastroduodenal ulcers. Patients and methods. Data from 102 patients who underwent emergency surgery for peptic ulcer perforation were recorded prospectively. To evaluate morbidity and mortality ulcer perforation was classified into three types: type A, solitary peripyloric ulcer located anteriorly in which laparoscopic closure by suture with omentoplasty was treatment of choice and postoperative endoscopic biopsy was mandatory; type B, perforated ulcer with large defect in which excision and suture was necessary; type C, complicated perforated ulcer with destruction of proximal duodenum and penetration into adjacent organs in which resectional surgery was indicated. Results. Morbidity and mortality were significantly lower in type A (9%, 4%, respectively) than types B (22%, 20%) and C (34%, 17%). Closure of type A perforation was managed laparoscopically in all cases. Billroth II resection was performed in 75% of type C cases. Age, ASA status, and time of surgery were independent prognostic factors by multivariate analysis, with increased mortality in patients older than 65 years, ASA III and IV, and surgery after 24 h following onset of symptoms. Conclusions. Prognosis of perforated ulcer disease is highly correlated with age, comorbid conditions (ASA status), and time of surgery. The proposed classification system helps to determine patients at risk of mortality.

Background and aims: This study examined the prognostic value of the cyclin-dependent kinase inhibitors p21Waf1/Cip1 and p27Kip1, and the cell cycle regulating proteins cyclin D1 and p53 after curative surgery for rectal cancer. Patients and methods: Formalin-fixed, paraffin-embedded tissue samples of 160 rectal carcinomas resected curatively within a 5-year period were used. Immunohistochemical analysis used monoclonal antibodies p21Waf1/Cip1 (clone SX118), p27Kip1 (clone SX53G8), cyclin D1 (clone DCS-6), and p53 (DO-1). Positive nuclear protein expression was assessed at the 10% level. Results of immunohistochemistry were studied for correlation with clinical and histopathological data of the prospective tumor registry including recurrence and patient survival. Results: Of the 160 rectal carcinomas 36% were p21Waf1/Cip1 positive, 44% p27Kip1 positive, 48% cyclin D1 positive, and 39% p53 positive. The p21Waf1/Cip1 staining pattern was correlated with p27Kip1 and p53 expression and with UICC stage and lymph node status. p53 status was not correlated to any clinical or histopathological variable. p27Kip1 expression was associated with tumor size and cyclin D1 expression. Tumor progression caused by local and distant recurrence occurred in 20%. p21Waf1/Cip1, p27Kip1, and p53 were strong predictors of recurrence. p21Waf1/Cip1 and p53 but not p27Kip1 were independently correlated with disease-free survival. UICC stage was independently related to both recurrence and survival. The best prognosis was in p21Waf1/Cip1 positive and p53 negative rectal carcinomas. Conclusions: Reflecting tumor biology by immunohistochemical assessment of cell cycle regulators, p21Waf1/Cip1 and p53 were independently predictive of prognosis in rectal cancer, and p27Kip1 was independently related to recurrence. However, cyclin D1 had no independent relationship to prognosis. Clinically, UICC stage was a strong predictor of prognosis after curative surgery for rectal cancer.

Ulcerative colitis patients are at increased risk for developing colorectal carcinomas. Despite expensive surveillance programmes, clinical practice reflects an uncertainty in individual risk assessment. The aim of the study was to evaluate independent cellular features with possible predictive value.Two patient groups were selected: group A comprised 8 patients with ulcerative colitis-associated colorectal carcinomas, group B comprised 16 ulcerative colitis patients with risk factors (duration of disease, extent of inflammation, epithelial dysplasias). A total of 683 paraffin-embedded mucosal biopsies were retrospectively evaluated for inflammatory activity, grade of dysplasia, ploidy status, laminin-5 gamma2 chain and cyclin A expression.Mild or moderate inflammatory activity was present in 78% of all biopsies, low- or high-grade dysplasia in 5.5%. There was no difference in inflammatory activity and dysplasia between patient groups. In group A, 75% of the biopsies exhibited aneuploid DNA distribution patterns. Group B showed mainly proliferative-diploid cell populations (85% / P = 0.006). Laminin-5 gamma2 chain was expressed in 13% of all biopsies, with a higher frequency in group A (P = 0.002). Cyclin A expression was found in 98% of all biopsies, with a higher number of immunopositive cells in group A biopsies (P = 0.014).Combined nuclear DNA assessment, laminin-5 gamma2 chain and cyclin A expression may help to identify ulcerative colitis patients with an increased risk for cancer development.

Aims: The aim of our study was to identify tumor cells in peritoneal lavage comparatively with immunocytochemistry (ICC) and half-nested reverse transcriptase-polymerase chain reaction (RT-PCR) using carcinoembryonic antigen (CEA) as marker and to evaluate their prognostic significance. Patients and methods: In 75 patients who underwent surgery for a carcinoma of the colorectum (n=49), stomach (n=17) or pancreas (n=9) and 13 patients with an abdominal aortic aneurysm (control group) the abdomen was irrigated with saline solution immediately after laparotomy. Cells were separated by Ficoll-density centrifugation and divided into 2 equal volumes for ICC and RT-PCR. For ICC cells were spun onto slides by cytospin centrifugation and stained with a monoclonal antibody (mab) against CEA using the APAAP method. For RT-PCR total RNA was extracted from the cells, transcribed into cDNA and amplified with CEA-specific primers. Lavages of 13 patients with an abdominal aortic aneurysm and blood samples of 6 healthy donors served as controls. Results: Immunostained tumor cells were found in peritoneal lavage in 23% (17/75) of all patients, whereas 63% (47/75) of patients gave a positive result by RT-PCR analysis. In the control group (n=13) no patient presented with tumor cells in ICC, however 5 of 13 (38%) showed amplified CEA-mRNA by RT-PCR, and so did one of six blood samples. Using ICC technique, we found significant correlations between detection rates and pT-, pN-, pM-categories as well as tumor stage. On the contrary, by RT-PCR significant correlations were observed only between pT- and pM-categories and detection rates. Detection of tumor cells in peritoneal lavage with both techniques was associated with poor prognosis. Moreover, these tumor cells are an independent prognostic factor and may have an influence on the development of peritoneal carcinomatosis. Conclusion: ICC is a useful method for detection of tumor cells in peritoneal lavage. In contrast, half-nested RT-PCR cannot be recommended, as the detection rates are unproportionally high, obviously as a result of CEA-mRNA expression in nontumor cells.

We evaluated p53 autoantibodies (p53-Ab) as a preoperative tumor marker and as a prognosis marker. We also investigated whether p53-Ab production is dependent on p53 protein overexpression in tumor tissue or on tumor volume. Serum samples of patients with a colorectal cancer (n = 130) and of healthy controls (n = 44) were examined for p53-Ab using an ELISA kit. P53 protein expression in tumor tissue was demonstrated immunohistochemically and quantified by ELISA. Tumor volume was calculated and patients' survival computed using the Kaplan-Meier method. p53-Ab were detected in the serum from 15% of patients; all controls were negative. There was a significant correlation between p53-Ab production and positive immunostaining or p53 protein concentration in tumor tissue. p53-Ab were detected at a higher percentage of patients with a tumor volume of 10 cm3 or greater than in those with a smaller tumor. No difference in patients' prognosis was found between the p53-Ab positive and negative groups. Because of their low sensitivity (15%) p53-Ab are not suitable as a preoperative tumor marker. However, their high specificity (100%) and their potential for early diagnosis of a tumor relapse makes them valuable for postoperative monitoring during follow-up in p53-Ab positive patients. Furthermore, their detection can be used as a simple serological test for early detection of p53 alterations.

Laparoscopic colorectal procedures offer several benefits postoperatively, including reduction of pain, minimal impairment of pulmonary and gastrointestinal function, and improved reconvalescence. At present, laparoscopic resections for colorectal cancer are discussed controversially due to oncologic radicality, potential tumor dissemination, and the fundamental problem of port-site metastases. Oncologic standards of open surgery for colorectal cancer are not compromised by the laparoscopic technique. Short-term results of both retrospective and prospective trials comparing open with laparoscopic surgery for colorectal cancer showed comparable oncologic outcomes related to recurrence and survival. Despite extensive research efforts, neither the incidence of port-site recurrence nor its causes have been clarified definitely. However, according to the preliminary results of recently published studies, the problem of port-site metastases may not be an inherited detriment of laparoscopic surgery, but rather an unfortunate sequel to the learning curve of the application of laparoscopic surgery in colorectal cancer. Finally, as long-term results of prospective randomized trials are still missing, the crucial issue whether laparoscopic resection for colorectal cancer is oncologically equivalent to open surgery, cannot be answered definitely. Therefore, in the interim, laparoscopic curative resections in colorectal cancer are only to be offered within prospective randomized trials.

The aim of this study was to evaluate the prognostic value of p53 nuclear accumulation and Bcl-2 expression after curative surgery for rectal cancer. Immunohistochemistry was performed using monoclonal antibodies (MAb) (DO-1 for p53; anti-human Bcl-2 MAb, clone 124, for Bcl-2) on formalin-fixed, paraffin-embedded tissues of 160 rectal carcinomas (UICC stages I-III), and results were compared with data from the prospective registry of rectal cancer by univariate and multivariate logistic regression model focusing specifically on recurrence. Survival was calculated by the Kaplan-Meier method and proportional hazards model. p53 nuclear accumulation was documented in 39% (n=63) of tumours and was associated with a higher incidence of tumour progression (local or distant recurrence) and poorer disease-free survival (P

Background: Intestinal bleeding of unknown origin can lead to a difficult workup. Abdominal colic, melena/hematemesis, and jaundice represent the pathognomonic triad for hemobilia, but clinical presentation and etiology of this entity are varying. Seldom all of these symptoms are present, and rarely does hemobilia cause melena or hematemesis. Often the correct diagnosis is missed. Patients frequently have a long history of complaints and inadequate therapy. Case Report: We report on a patient who complained of repeated, severe epigastric pain and massive melena induced by exercise activity. After 2 years of complaints and an unnecessary operation, ultrasound detected a liver hemangioma. It was supposed that the hemangioma was causing hemobilia during strenuous physical activity. The patient underwent a partial liver resection to eliminate the hemangioma. All complaints resolved, and the patient remained asymptomatic postoperatively. Conclusions: Physicians should be aware of hemobilia as a rare cause of upper gastrointestinal bleeding, especially if esophagogastroduodenoscopy cannot demonstrate any bleeding source. Ultrasound is able to visualize many diseases leading to hemobilia and should be integrated into the early workup of unclear intestinal bleedings.

Background: Radical lymphadenectomy for colorectal cancer according to its arterial supply seems to remove potentially me-tastatic lymph nodes and highlights the impact on prognosis. Standards and controversies: Systematic lymph-node dissection in colorectal cancer requires knowledge of normal anatomy of lymphatic drainage and spreading of lymph-node metastases. Oncological standards of curative surgery for colorectal cancer include en bloc resection, no-touch isolation technique, primary ligation of the vessels and systematic lymphadenectomy. In rectal cancer, total mesorectal excision and irrigation of the rectal stump is mandatory. Potential improvements in prognosis achieved by extended lymph-node dissection have to compete with procedure-related morbidity. High-tie ligation of the inferior mesenteric artery is a controversial issue. Prediction of prognosis is essential for planning a treatment schedule for patients. Conclusions: At present, clinicopathological stage is the single most reliable factor in prediction of outcome. New encouraging methods for detecting micrometastases of lymph nodes and new surgical technologies such as immune corrective surgery are challenging and have to be critically assessed. The results of laparoscopic surgery for the cure of colorectal cancer have to be proven within prospective randomised trials.

This study assessed the results of laparoscopic stoma creation for fecal diversion. All patients who underwent elective laparoscopic stoma creation as the sole procedure were evaluated prospectively. Univariate analysis was performed to determine whether previous abdominal surgery, age, gender, body mass index, indication, or surgeons' experience has an effect on the outcome. Between November 1992 and May 1998, 42 patients (17 males, 25 females) with a mean age of 62.1 years (range 17-91) underwent laparoscopic stoma formation. Fecal diversion included loop ileostomy (n = 7), loop sigmoid colostomy (n = 32), and end-sigmoid colostomy (n = 3). Most common indications were unresectable rectal cancer, rectal obstruction caused by advanced pelvic tumors and benign disorders such as perianal Crohn's disease, and fecal incontinence. Of the 42 procedures 41 were completed laparoscopically (97.6%). Complications occurred in four patients (9.5%) requiring reoperation in two (4.8%). Mean length of surgery was 74.4 min (range 30-200). First bowel movements resumed on the 3rd day (range 2nd-7th) after surgery and patients were discharged from hospital after 13 days (range 6-47). Short-term results (> 30 days-1 year) indicated that no further stoma-related complications occurred. Analyzing factors potentially predictive of outcome, no statistically significant differences were documented in relation to previous abdominal surgery, age, gender, body mass index, indication, or surgeons' experience (P > 0.05). Laparoscopic stoma creation is appropriate to achieve fecal diversion because it is technically feasible and can be performed with low morbidity. In addition to the benefits of the minimally invasive technique for the patients, laparoscopic stoma formation can be ideal for the surgeon as basic and initial step to perform laparoscopic colorectal procedures.

The aim of this study was to examine the expression of P-glycoprotein (Pgp) and MDR1 mRNA, in gall bladder carcinoma, a chemo-resistant tumour. 26 cases of gall bladder cancer and nine samples of normal gall bladder archival paraffin blocks were investigated for the presence of Pgp protein with immunohistochemistry (IHC) and MDR1 RNA by reverse transcription-polymerase chain reaction (RT-PCR). Monoclonal antibodies JSB-1 and UIC-2, recognising separate epitopes of Pgp, were used for IHC. For RT-PCR, total RNA was extracted from paraffin-embedded tissue. After RT, the samples were subjected to nested PCR (NPCR) using primers specific for the MDR1 gene, and evaluated by electrophoresis. In gall bladder carcinoma, the percentage of positive cases expressing Pgp (77% for JSB-1, 69% for UIC-2) and MDR1 mRNA (52%) was significantly higher than those in normal gall bladder. In earlier TNM stages Pgp and MDR1 mRNA were more frequently expressed (non-significant) than in advanced stages. The results of this study suggested that overexpression of MDR1 mRNA and Pgp in gall bladder carcinoma tissue probably is a very important reason why gall bladder cancer is generally not responsive to chemotherapy.

Seit Mitte der 80 er Jahre wird weltweit uber eine zunehmende Anzahl schwerster Infektionen durch Streptokokken der Gruppe A (Streptococcus pyogenes) berichtet. Betroffen sind haufig jungere, gesunde Patienten nach Bagatellverletzungen. Gekennzeichnet ist die Erkrankung durch einen raschen Verlauf mit Schock, Sepsis, Multiorganversagen, Weichgewebsnekrosen und eine hohe Letalitat. Fur dieses spezielle Krankheitsbild wurde der Name „streptococcal toxic shock-like syndrome“ gepragt. Pathogenetisch scheinen die sog. M-Proteine, insbesondere die Typen 1 und 3, sowie das „streptococcal pyrogenic exotoxin A“ (speA) eine wichtige Rolle zu spielen. Therapeutisch stehen eine hochdosierte antibiotische Therapie, intensivmedizinische Uberwachung sowie das fruhzeitige, aggressive und meist mehrfache Debridement der Weichgewebsnekrosen ganz im Vordergrund, um das Leben der Patienten zu retten.

Laparoscopic colon and rectum operations expose peripheral nerves to risk due to extreme patient positions needed to achieve gravity displacement during the surgical procedures. The general incidence of position-caused nerve injuries in surgery is not well known and is estimated to be about 0.5 % in the literature. There are no current data concerning laparoscopic operations. This study assesses the incidence and outcome of surgery-associated neurological symptoms after laparoscopic colon and rectum surgical procedures. We analysed the number of position-caused nerve injuries and their outcome from 1992-2010 in a prospectively managed data base. Risk factors like age, BMI, procedure duration and abduction of the upper extremities were analysed. There were 19 (0.7 %) position-caused nerve injuries among 2698 laparoscopic operations on the colon and rectum. The incidence of surgery-associated neurological symptoms was 1.08 % after laparoscopic rectum and 0.54 % after laparoscopic colon surgical procedures. Both operation time (267 vs. 185 minutes) and BMI (27.93 vs. 25.79 kg/m(2)) were revealed as risk factors for position-caused nerve injuries. Adduction of the upper extremities reduced the incidence of positioning nerve injuries from 0.23 % to 0.1 %. Postoperative neurological symptoms were in most cases reversible (89.47 %). The incidence of postoperative nerve injuries since 2007 is low after laparoscopic rectum and colon operations and is mostly completely reversible. Both procedure duration and BMI are probable risk factors for surgery-associated nerve injuries. Adduction of the upper extremities provides an opportunity to reduce position-caused nerve injuries.

The gastric and duodenal perforations are a life-threatening complication of peptic ulcer disease with the indication for immediate surgical intervention. To which extent laparoscopy is a suitable method in an acute situation was examined in the present investigation.The data of all patients within a period of 15 years (01/1996-12/2010) who were operated laparoscopically because of a perforated gastric or duodenal ulcer, were collected prospectively in terms of age, gender, localisation of perforation, diagnostics, symptoms, surgical procedures, intraoperative and postoperative complications and postoperative course, and were analysed retrospectively.During the observation period 45 patients were operated laparoscopically due to gastric or duodenal perforation. The median age at operation was 58 (18-91) years. An NSAID medication was present in 11 (24.4 %) patients. The perforation was juxtapyloric in 12 (26.7 %) patients, postpyloric in 10 (22.2 %) patients, one (2.2 %) patient in each small and greater curvature, in 18 (40.0 %) at the front and in three (6.7 %) patients on the rear wall. In two cases, previous surgical treatment in the upper abdomen was performed. After primary diagnostic laparoscopy, an indication for conversion was seen in 20 (44.4 %) patients. During laparoscopically completed operations simple suturing was done in 18/25 (72.0 %) patients and excision and suturing was performed in 7/25 (37.8 %) patients. After conversion simple suturing was observed in 7/20 (35.0 %) patients, whereas in 10/20 (50.0 %) patients excision and suturing was performed. 3/20 (15.0 %) patients underwent a resective operation. The median operative time was 105 (40-306) minutes and mean hospitalisation 11 (4-66) days. The ICU stay was in median 2 (0-37) days. Major complications were seen in 11 (24.4 %) patients, namely re-laparotomy (n = 7; 15.6 %) and haemorrhage (n = 4; 8.9 %). Minor complications were observed in 8 (17.8 %) of cases. The mortality rate was 11.1 % (n = 5).The laparoscopic treatment of gastric and duodenal perforations is a minimally invasive therapeutic option for the definitive treatment of this life-threatening disease. The indication for a laparoscopic approach has to be considered individually and depends to a decisive extent on the experience of the laparoscopic surgeon.

Neuroendocrine neoplasia (NEN) are a rare and heterogenous tumour entity. The subgroup with unknown primary tumour (N-CUP) seems to have a worse prognosis as resection of the primary is necessary for cure. The diagnostics and therapeutic algorithms for N-CUP in a German single centre are presented.Analysis of the surgical databank showed 35 cases of N-CUP in 261 cases with NEN from gastroenteropancreatic and lung origin over 2 decades (03/1990-03/2011). Three groups were built: K1 - primary detection after operative exploration (n = 10), K2 - unknown primary after operative exploration (n = 10) and K3 - no operative exploration for various reasons (n = 13).Initially 13.4 % (35/261) of patients presented as N-CUP, after intensified diagnostics 12.7 % (33/261) and after operative exploration 8.8 % (23/261) remained with unknown primary tumour. The sex ratio was 1 : 1, the median age is significantly higher in N-CUP [63.8 years (y) vs. 55.9 y, p = 0.004), the 5-year-survival is lower (58 vs. 72 %, n. s.). compared to NEN with known primary. Operative exploration was performed in 60.6 % (20/33), 30 % (6/20) of them were found to have inoperable situations, in 20 % (4/20) single site metastases were removed completely and in 50 % (10/20) a primary tumour was detected (8 × midgut, 2 × pancreas) intraoperatively. In these cases 70 % (7/10) got complete tumour resection (R0) and in 30 % (3/10) primary tumour resection with debulking of liver metastasis was done. In K3 (39.4 %, 13/33) most patients [69.2 % (9/13)] were treated with chemotherapy. The median age in K1 was significantly lower than in K3 (54.9 y vs. 68.3 y, p = 0.028), male dominance was seen in K3 (3,3 : 1, n. s.). The average Ki-67 index was 4.3, 23.8 and 53 % in K1, K2 and K3 (p 0.0001 for K1 and K3 and p = 0.035 for K2 and K3), respectively. The death rate was 20, 30 and 76.9 % in K1, K2 and K3, respectively.Primary tumours of the midgut and pancreas are often found in the subset of well differentiated neuroendocrine CUP syndrome after open surgical exploration. A high rate of complete tumour resection and cure can be achieved in these cases. After common diagnostic tools (CT, MRI and somatostatin receptor scintigraphy), immunhistochemistry can give important hints (CDX-2 for midgut, TTF-1 for lung and thyroid) for a primary lesion. Also in single site metastasis without primary tumour detection a good clinical outcome is seen after complete resection.

Anorectal outlet obstruction constitutes one form of chronic constipation. Combinations of morphological alterations of the pelvis, the pelvic floor and the colorectum are nearly always evident. The goal of the diagnostic work-up is to identify those patients who will profit from a surgical intervention. Resection rectopexy aims at restoring the physiological anatomy thereby ameliorating the functional interaction of structures effected with the laparoscopic approach entailing all advantages of minimally invasive surgery. Besides a detailed description of the surgical technique used and an algorithm for indications to operate we present our results after 19 years of experience. Throughout this period, 264 laparoscopic resection rectopexies for outlet obstruction were performed. With a mean follow-up of 58.2 months the rate of improvement of obstructive symptoms was 79.5 % (n = 128 of 161 available for follow-up). Present studies suggest that (laparoscopic) resection rectopexy entails better results in comparison to non-resecting procedures and procedures with the implantation of allogenic material. Certainly, in order to achieve these results a correct patient selection and an expertise in laparoscopic surgery are essential. Both the perioperative and the functional results of our own collective fortify the advantages of laparoscopic resection rectopexy in patients with an outlet obstruction.

In obstructive defecation syndrome (ODS) combinations of morphologic alterations of the pelvic floor and the colorectum are nearly always evident. Laparoscopic resection rectopexy (LRR) aims at restoring physiological function. We present the results of 19 years of experience with this procedure in patients with ODS.Between 1993 and 2012, 264 patients underwent LRR for ODS at our department. Perioperative and follow-up data were analyzed.The female/male ratio was 25.4:1, mean age was 61.3 years (±14.3 years), and mean body mass index (BMI) was 25.2 kg/m(2) (±4.2 kg/m(2)). The pathological conditions most frequently found in combination were a sigmoidocele plus a rectocele (n = 79) and a sigmoidocele plus a rectal prolapse or intussusception (n = 69). The conversion rate was 2.3 % (n = 6). The mortality rate was 0.75 % (n = 2), the rate of complications requiring surgical re-intervention was 4.3 % (n = 11), and the rate of minor complications was 19.8 % (n = 51). Follow-up data were available for 161 patients with a mean follow-up of 58.2 months (±47.1 months). Long-term results showed that 79.5 % of patients (n = 128) reported at least an improvement of symptoms. In cases of a sigmoidocele (n = 63 available for follow-up) or a rectal prolapse II°/III° (n = 72 available for follow-up), the improvement rates were 79.4 % (n = 50) and 81.9 % (n = 59), respectively.LRR is a safe and effective procedure. Our perioperative results and long-term functional outcome strengthen the evidence regarding benefits of LRR in patients with an outlet obstruction. However, careful patient selection is essential.

The rectovaginal fistula is a rare entity with heterogenic causality. Its genesis seems to predict the extent of operative treatment and the prognostic outcome. The aim of this study was to present different surgical techniques in the treatment of rectovaginal fistulas and their results in correspondence to the genesis.Between 1 / 2000 and 1 / 2010, the data of patients with rectovaginal fistulas were collected. The retrospective analysis included biographic and anamnestic data as well as clinical parameters, general and specific complications and postoperative data.In a timespan of ten years 36 patients with rectovaginal fistulas were treated. The most common causes were inflammatory diseases (n = 21) and earlier surgical measures (n = 6). Moreover tumour-associated fistulas (n = 5) and fistulas with unknown genesis (n = 4) were seen. As surgical techniques anterior resection (n = 21), transrectal flap plasty (n = 7), subtotal colectomy (n = 3), pelvine exenteration (n = 2) and rectal exstirpation (n = 1) were used. The closure of the vaginal lesion was performed by single suture (n = 25), flap plasty (n = 6), transvaginal omental plasty (n = 2) and posterior vaginal plasty (n = 1). All patients were provided with an omental plasty to perform a safe division of the concerned regions. Patients with a low fistula (6 cm) were treated with transperineal omental plasty. The median follow-up was 12 months (6 - 36). Within this timespan 6 patients suffered from major complications [ARDS, anastomosis insufficiency, postoperative bleeding, recurrence of fistula (n = 3)]. Three patients died in the postoperative period (cerebellar infarct, septic complication associated with Crohn's disease, multiorgan failure in tumour recurrence).The genesis of rectovaginal fistulae is an important predictor for the size of resection which can range from simple excision to exenteration. For optimal therapy the surgical intervention needs to be integrated into an interdisciplinary therapy concept.

Spinal anesthesia causes sympathetic blockade which leads to changes in the local temperature of the skin surface due to hyperemia.These changes in skin temperature were used in a newly developed method for estimating the level of analgesia. A total of 11 patients who were scheduled for surgical procedures of the lower extremities with symmetrical spinal anesthesia were included in the clinical study. By means of an electronic digital multi-channel body temperature measurement device with eight high precision temperature sensors placed on defined dermatomes, patient skin temperature was continuously measured at 2 s intervals and documented before, during and for 45 min after spinal anesthesia. Simultaneously, a neurological pin-prick test was carried on at regular intervals every 2 min on the defined dermatomes to calculate the correlation between the effects of analgesia and corresponding changes in skin temperature.The analyzed correlations showed that there is a minimum of 1.05°C temperature difference before and after spinal anesthesia especially on the lower extremities (foot, knee, inguinal) of patient dermatomes. The collected data of varying temperature differences were systematically evaluated using statistical software which led to a deeper understanding of the interdependency between temperature differences at different dermatomes. These interdependencies of temperature differences were used to develop a systematic analgesia level measurement algorithm. The algorithm calculates the skin temperature differences at specified dermatomes to find the accurate level of analgesia and also to find the forward and reverse progresses of analgesia. The developed mathematical method shows that it is possible to predict the level of analgesia up to an accuracy of 95% after spinal anesthesia.Therefore, it can be concluded that systematic processing of skin temperature data, collected at defined dermatomes can be used as a promising parameter for predicting surgical tolerance. The objective is to improve this experimental method with an extended patient population study.

Deep rectovaginal fistulas are a rare entity and pose a delicate challenge for the surgeon. The present study introduces different operative interventions involved in transperineal omental flap surgery.A retrospective analysis of all patients treated with a low or mid rectovaginal or enterovaginal fistula at the Department of Surgery of the University Hospital of Schleswig-Holstein, Campus Luebeck, was performed. Treatment results were discussed with respect to aetiology, localization, morbidity and outcome.Between the years 2000 and 2010, a total of nine patients with a low or mid rectovaginal fistula were treated at our clinic. After local fistulectomy, all patients were additionally treated by a laparoscopically assisted omental flap reconstruction of the rectovaginal and perineal space. Eight of the nine patients received a protective ileostomy or colostomy. Only the patient with a history of Crohn's disease had no ileostomy raised. At a median follow-up of 22 months, no patient experienced recurrence of a rectovaginal fistula. Perioperative mortality was zero and minor complications were observed in 22%. Major complications were an anastomotic insufficiency after low anterior resection that was treated without further interventions. Another complication was a persistent fistula within the sphincter that needed re-operation and bovine plug repair combined with a mucosa flap.Complete omental reconstruction of the rectovaginal space appears decisive in the operative therapy of deep rectovaginal or enterovaginal fistulas. Comparative studies on standard therapies are necessary although direct comparison of case series is difficult.

Medical devices must be safe and functioning states the law. Treatments with medical devices need not be efficacious to be allowed. We investigated special requirements and problems arising from the law.The market for medical devices is contrasted with that for drugs. The requirements of relevant laws are discussed. Finally, published clinical studies on anal incontinence are analysed with respect to their methodological quality.Clinical trials of medical devices for treat-ing anal incontinence are of poor methodological quality thus preventing evaluation of the devices' utility.Large, high quality clinical studies of the efficacy of medical devices for treating anal incontinence are urgently needed. Only such studies enable health technology assessment and comprehensible decisions on reimbursement by health insurance.

Anesthesia per se and pneumoperitoneum during laparoscopic surgery lead to atelectasis and impairment of oxygenation. We hypothesized that a ventilation with positive end-expiratory pressure (PEEP) during general anesthesia and laparoscopic surgery leads to a more homogeneous ventilation distribution as determined by electrical impedance tomography (EIT). Furthermore, we supposed that PEEP ventilation in lung-healthy patients would improve the parameters of oxygenation and respiratory compliance.Thirty-two patients scheduled to undergo laparoscopic cholecystectomy were randomly assigned to be ventilated with ZEEP (0 cmH(2)O) or with PEEP (10 cmH(2)O) and a subsequent recruitment maneuver. Differences in regional ventilation were analyzed by the EIT-based center-of-ventilation index (COV), which quantifies the distribution of ventilation and indicates ventilation shifts.Higher amount of ventilation was examined in the dorsal parts of the lungs in the PEEP group. Throughout the application of PEEP, a lower shift of ventilation was found, whereas after the induction of anesthesia, a remarkable ventral shift of ventilation in ZEEP-ventilated patients (COV: ZEEP, 40.6 ± 2.4%; PEEP, 46.5 ± 3.5%; P0.001) was observed. Compared with the PEEP group, ZEEP caused a ventral misalignment of ventilation during pneumoperitoneum (COV: ZEEP, 41.6 ± 2.4%; PEEP, 44 ± 2.7%; P=0.013). Throughout the study, there were significant differences in the parameters of oxygenation and respiratory compliance with improved values in PEEP-ventilated patients.The effect of anesthesia, pneumoperitoneum, and different PEEP levels can be evaluated by EIT-based COV monitoring. An initial recruitment maneuver and a PEEP of 10 cmH(2)O preserved homogeneous regional ventilation during laparoscopic surgery in most, but not all, patients and improved oxygenation and respiratory compliance.

Iatrogenic colon perforation is a rare but life-threatening complication of colonscopy. As in other diseases, laparoscopic treatment has increasingly been propagated for the treatment of colonic disorders in the last years. The aim of this comparative study was to answer the question of whether laparoscopic surgical treatment may serve as a suitable treatment for the acute colon perforation comparable to open surgery.The data of all patients who underwent surgery for iatrogenic colon perforation within a 13-year time period (1997-2009) were recorded prospectively and analysed retrospectively with regard to different perioperative parameters. In the following analysis the laparoscopically and open surgically treated patients were compared.In the observation period 24 patients with iatrogenic colon perforation were treated laparoscopically and 12 patients with open surgery. There were no significant differences concerning age in both groups. In both groups resection of the affected region was preferred [open surgically: 58 % (n = 7), laparoscopically: 80 % (n = 19)]. The median operation time was 105 min (range: 35 - 180) for the open surgically treated patients and 165 min (90 - 420) for laparoscopic procedures (p = 0.006). In 4 cases of the laparoscopic group a conversion via laparotomy was -necessary. There was no significant difference concerning the hospital stay between both groups with 14.5 days (7-40) for the open surgical and 11 days (7-25) for the laparoscopic group. Concerning the postoperative morbidity a significantly higher incidence could be seen in the open surgical group (p0.0001).An iatrogenic colon perforation mostly leeds to the immediate indication for a surgical treatment. The morbidity and mortality is -primarily determined through the appearance of postoperative complications due to delays in diagnostics and treatment. In this study the feasibility of a laparoscopic treatment could be shown. The laparoscopy with its minimal access trauma offers an enlargement of the diagnostics as well as a safe treatment of the perforation in most patients. However, the laparoscopic treatment especially in emergancy situations requires -advanced experience of the surgeon and always needs a critical benefit-risk consideration in the individual situation.

Due to logistic, organizational and economic advantages, interdisciplinary emergency centers are gaining more and more acceptance compared to established, discipline-specific and independent emergency rooms. Organizational concepts for interdisciplinary emergency centers need to consider the mandate for comprehensive patient care and the consequential performance spectrum. Thus, the implementation of generally accepted guidelines and specifications is demanding.Currently developed concepts of the accordant interdisciplinary working groups try to fulfill these premises. Further fundamental criteria to be met are the quality and education of medical and nursing staff, which are predominantly doing their jobs within the interdisciplinary emergency centers. The concept of the German surgical societies and connected organizations is not the implementation of a new definition of the role of emergency specialized physicians but rather a substantial advancement of the existing and established regulations for further education. Therefore, a further advanced-training program for clinical emergency medicine has to be implemented in addition to the existing emergency education within the common trunk, which every physician has to pass through during discipline-specific education. Furthermore, this program should complement the existing pre-clinical emergency education, which can be acquired after specialization.The accordant criteria to be developed and the coordination with the German Medical Association (Bundesärztekammer) are currently prioritized on the agenda of the interdisciplinary working group. Due to reasons of compatibility with the regulations for further education, specific management skills for future heads and directors of such interdisciplinary emergency centers should not be stipulated within the advanced-training program for clinical emergency medicine but should be gained through specific course concepts beyond this program.

To date laparoscopic hepatic surgery is only common in a few centres for a specific selected patient group. The intention of this survey was to estimate the current state of affairs for laparoscopic hepatic surgery in Germany at 2008.A questionnaire was prepared and sent out by e-mail in May 2009 to the members of the DGAV (German Society of General and Visceral Surgery). The feedback was evaluated anonymously.A total of 181 answers were received by 31st July 2009 (return rate of 15.9%). The return rate of basic and standard care hospitals was 9.2%, specialized hospitals 23.6%, hospitals with maximum care 50% and university hospitals had a return rate of 71.9%. The question whether laparoscopic hepatic surgery had been performed in 2008 was answered with YES by 125 (69.1%) and NO by 54 (29.8%) members. The number of laparoscopic hepatic surgery interventions (laparoscopic ultrasound, laparoscopic radiofrequency ablation and resection) in 2008 was given as more than 50 by 4 (2.2%) hospitals, between 20 and 50 by 11 (6.1%) hospitals, between 10 and 20 by 23 (12.7%) hospitals, between 5 and 10 by 45 (24.9%) hospitals and between 0 and 5 by 54 (29.8%) hospitals. In 2008 the frequency of laparoscopic ultrasound during intraoperative staging to confirm the diagnosis ranged from 2 to 250, whereby 96.4% of the hospitals had less than 50 and only 2 hospitals (2.7%) had 211 and 250 examinations, respectively. 50 hospitals carried out laparoscopic radiofrequency ablation (RFA). 69 (38.1%) of the interviewed hospitals reported hepatic laparoscopic resections (n=551).Laparoscopic liver surgery has been done in Germany in patients with benign or malignant liver lesions. Pure laparoscopy is the most common access. Atypical resections are the primarily indication followed by left lateral resections. All further types of resection have been done in a very small number. Laparoscopic liver surgery has been performed in all types of hospitals.

Acute gastrointestinal bleeding (AGIB) requiring transfusion and surgical treatment still constitutes a life-threatening situation. The purpose of this paper was to examine the treatment outcome for this group of patients as a function of various risk factors and to present our diagnostic and therapeutic regime.A retrospective analysis of data from 154 patients with AGIB who underwent surgical procedures and received massive transfusions in a university hospital between 1999 and 2008 was carried out.The patients were divided into two groups. Group I include 91 patients with acute upper gastrointestinal bleeding and group II included 63 patients with lower gastrointestinal bleeding. The average age was 67 years (range 29-93 years) in group I and 70 years (39-97 years) in group II. The initial hemoglobin level was 8.4 g/dl in group I and 10.5 g/dl in group II. Univariate analysis of mortality revealed the following significant risk factors for group I: postoperative need for ventilation (p=0.007), prolonged ICU stay (p=0.004) and anticoagulants in the medical history. The risk factors in group II were blood transfusions10 units (p=0.031), postoperative need for ventilation (p=0.004), necessary reoperations (p=0.016) and an initial hemoglobin level8.0 g/dl (p=0.043). The complication rate was 76.9% (mortality rate 34.1%) in group I and 60.3% (mortality rate 15.9%) in group II.Examination and stabilization of the patient is directly followed by diagnostic localization. The indication for surgery is mainly limited to peracute, uncontrollable and recurrent forms of gastrointestinal bleeding. The mortality rate for these critically ill, negatively selected patients remains high and could not be lowered in the last decade. Postoperative need of ventilation is a predictor for poor prognosis.

Laparoscopic Radiofrequency-ablation is a safe and effective method for tumor destruction in patients with unresectable liver tumors. However, accurate probe placement using laparoscopic ultrasound guidance is required to achieve complete tumor ablation. After development and evaluation of laparoscopic navigation tools for radiofrequency ablation, we are now presenting a prototype of a navigation- and documentation-system for laparoscopic RFA.An image-guided surgery system for laparoscopic liver treatments (LapAssistent) based on a 3D-navigation scene was developed. A laparoscopic ultrasound probe and a RFA needle could be navigated using an electromagnetic tracking system. The system was studied using a perfused tumour-mimic-model of a porcine liver.The study showed that laparoscopic ultrasound-guided navigation is technically feasible. The system enables the surgeon to intraoperatively update the three-dimensional planning data in case of new findings. The RFA needle could be placed accurately in a targeted tumour with a targeting error ranging from 5 - 7 mm, even out of the ultrasound plane. In case of multiple tumours lying in close spatial relationship, the documentation module helps to keep track of the already ablated tumours and those that still need to be treated.Laparoscopic radiofrequency ablation requires advanced laparoscopic ultrasound skills for accurate placement of the RFA probe. The system adds benefit to laparoscopic RFA enabling the surgeon to place the needle accurately inside the targeted tumours using the navigation scene. The possibility to update the three-dimensional model with new intraoperative findings enables the surgeon to adapt to a new intraoperative situation.

Mucoceles of the appendix are rare. After appendectomy, mucoceles are detected with a frequency of 0.2 to 0.3 %. Both stenosing / obliterating processes and alterations of the epithelium (hyperplasia, mucinous cystadenoma, cystadenoma with uncertain malignant potential (UMP), mucinous cystadenocarcinoma lead to the occurrence of mucoceles. The perforation of a mucocele with possible spread of mucus and cells into the abdominal cavity constitutes a severe complication (pseudomyxoma peritonei). Surgical resection is the curative approach for mucoceles of the appendix.Data of patients who were treated for an appendiceal mucocele between 1995 and 2009 were analysed retrospectively with regard to clinical presentation, diagnostic measures, surgical procedure and histopathological result. Follow-up was evaluated in telephone interviews.We extracted 5 cases from our database. Clinical symptoms varied greatly among the individual patients, ranging from peracute abdominal pain in the right lower quadrant to chronic obstipation. Results from abdominal ultrasound and / or abdominal CT scans contributed to the indication for surgical intervention in all cases. In 2 patients surgery was stated as urgent whereas in 3 the operation was scheduled electively. In one patient the diagnosis of an appendiceal mucocele was stated preoperatively and in another intraoperatively. In 3 patients only the histopathological result revealed the underlying mucocele. We performed 1 open and 1 laparoscopic appendectomy, 1 open appendectomy with a partial resection of the coecum and 2 laparoscopic ileocoecal resections. One of the patients had a pseudomyxoma peritonei. The histopathological diagnoses ranged from mere epithelial hyperplasia to an adenoma with uncertain malignant potential and a mucinous cystadenocarcinoma. One patient's long-term follow-up could not be evaluated. All other patients had neither recurrence nor any complications after discharge.Mucoceles of the appendix present with a wide spectrum of clinical symptoms and histopathological alterations. Only an accurate histological analysis reveals the underlying pathological lesion correctly. This study emphasises that a mucocele of the appendix constitutes an important differential diagnosis in patients presenting with pathologies in their right lower abdominal quadrant.

Objective Current criteria for performing relaparotomy for suspected peritonitis are non explicit and based on non-quantitative, subjective arguments or hospital practice. The aim of this study was to determine the value of routinely used clinical and diagnostic parameters in early detection of postoperative, diffuse peritonitis (PP). Furthermore, the prognosis and outcome after early indication for relaparotomy in patients with PP compared to community-aquired peritonitis (CAP) was evaluated. Methods Between 1999 and 2008, a total of 251 patients with diffuse secondary peritonitis either postoperative (PP) or community acquired (CAP) were analyzed retrospectively. PP (n = 114) and CAP (n = 137) were compared regarding physical examination, MPI-Score, APACHE II-Score, evidence of organ failure, laboratory parameters, diagnostic instruments and clinical course. The treatment regimen comprised surgical source control (with/without programmed lavage), abdominal closure and relaparotomy on demand, broad spectrum antibiotic therapy and intensive care support. Results The APACHE II-Score (20 CAP vs. 22 PP, p = 0.012), MPI-Score (27 CAP vs. 30 PP, p = 0.001) and the number of lavages differed significantly. Positive phyiscal testing and signs of sepsis [abdominal pain (81.6% PP vs. CAP 97.1%, p = 0.03), rebound tenderness (21.9% vs. 35.8%, p = 0.02), fever (35.1% vs. 51.8%, p = 0.03)] occurred significantly less often in the PP patients than in the CAP group. Conventional radiography (66.2%) and ultrasonography (44.3%) had a lower diagnostic sensitivity than did abdominal CT-scan (97.2%). Mortality was higher in the PP group but did not differ significantly between the two groups (47.4% PP vs. 35.8% CAP, p = 0.06). Conclusion The value of physical tests and laboratory parameters in diagnosing abdominal sepsis is limited. CT-scanning revealed the highest diagnostic accuracy. A treatment regimen of early relaprotomy appears to be the most reasonable strategy for as early discovery of postoperative peritonitis as possible.

CT scanning of the lungs is the standard procedure for preoperative evaluation of central lung tumors. The extent of the tumor and infiltration of central lung structures or lung segments are decisive parameters to clarify whether surgery is possible and the extent of resection. With computer-assisted methods for the segmentation of anatomical structures based on CT data (Fraunhofer MeVis, Bremen) an enhanced, three-dimensional selective visualization is now possible.From August 2007 through June 2009, 22 patients with central lung tumors were treated at the department of thoracic surgery, University of Schleswig-Holstein, campus Lübeck. There were 15 males and 7 females with a mean age of 60.2 years (range 41-74 years), 18 patients had a long history of smoking, while 4 patients had never smoked. Of the patients 20 had a primary lung carcinoma, 1 patient had local recurrent lung cancer after lobectomy and 1 patient had a central lung metastasis from a non-pulmonary primary carcinoma. A multi-slice detector computer tomogram (MSDCT) scan was performed in all cases. All data were three-dimensionally reconstructed and visualized using special computer-aided software (Fraunhofer MeVis, Bremen). Pulmonary lung function tests, computed postoperative lung volume, bronchoscopic findings, general condition of the patients and the three-dimensionally reconstructed CT data were used for an individual risk analysis and surgical planning.According to the risk analysis 14 out of the 22 patients were surgically treated, 7 patients were staged as functionally inoperable and 1 as technically inoperable. A pneumonectomy was performed in 5 cases, a lobectomy/bilobectomy in 4 cases, an extended lobectomy in 3 cases and 1 case each of a wedge resection and a sleeve resection. Of the 14 patients 2 were classified as stage Ia/b, 7 patients as stage IIa/b and 5 patients as stage IIIa. The median length of time spent in hospital was 8.5±33 days and the mortality rate was 0%. The three-dimensional visualization of the tumor and its anatomical relationship to central pulmonary vessels and the airway system was feasible in all cases. The three-dimensional reconstruction was confirmed in all cases by surgical exploration.Three-dimensional reconstruction of CT scan data is a new and promising method for preoperative presentation and risk analysis of central lung tumors. The three-dimensional visualization with anatomical reformatting and color-coded segmentation enables the surgeon to make a more precise strategic approach for central lung tumors.

Background Randomized trials in low-risk populations have failed to show any benefit for laparoscopic compared with open colorectal resection in terms of morbidity. Furthermore, it is not known whether laparoscopic colorectal resection would yield advantages if randomization were revealed during surgery after a diagnostic laparoscopy. Methods Patients with cancer of the colon or upper rectum were randomly assigned to laparoscopic or open resection. All patients underwent diagnostic laparoscopy to assess whether laparoscopic resection was feasible and the result of randomization was then revealed to the surgeon. Main endpoints were overall, general and surgical morbidity, and mortality. Results Some 679 patients underwent diagnostic laparoscopy which led to the exclusion of 207; 250 patients were allocated to laparoscopic and 222 to open resection. Conversion to laparotomy occurred in 28 patients (11·2 per cent). There were no differences in morbidity (overall 25·2 versus 23·9 per cent) or mortality (1·2 versus 0·9 per cent) between laparoscopic and open groups. Postoperative hospital stay was shorter after laparoscopic resection (median (range) 10 (1–123) versus 12 (4–109) days; P = 0·032). Conclusion Laparoscopic resection of colorectal cancer is associated with increased operating time but does not decrease morbidity even in a moderate-risk population.

Many different techniques to treat rectal prolapse have been introduced. Laparoscopic resection rectopexy has been shown to entail benefits regarding both perioperative results and short-term outcome, whereas data for long-term outcome are scarce. Between 1993 and 2008, all laparoscopic resection rectopexies for rectal prolapse II° or III° were selected from a prospective laparoscopic colorectal surgery database. We analyzed demographic, perioperative, and follow-up results. We defined two periods (1993–2000 and 2001–2008) for comparison of data. Long-term follow-up was obtained by sending questionnaires to all patients. Evaluation included constipation, incontinence, and recurrence of prolapse. Between January 1993 and November 2008, we performed 152 laparoscopic resection rectopexies for rectal prolapse. Median age was 64.1 years (±14.6). Conversion rate was 0.7% (1), mean operation time was 204 (±65.3) min, and was significantly shorter in the second period compared with the first (P

In laparoscopic colon surgery, endostaplers generate 2 parallel rows of staples. The aim of this paper is to analyse whether the introduction of a new endostapler generating a third row of staples influences the rate of anastomotic leakage and bleedings.362 patients of the Department of Surgery, University Clinic of Schleswig-Holstein, Campus Lübeck, were included in this study. All patients underwent colon resection with performance of double-stapling anastomosis. In Group I (n = 148; 7 / 2004 to 12 / 2005), the Endopath TSB 45 endostapler (2 rows of staples) was used, whereas in Group II (n = 214; 7 / 2006 to 12 / 2007), the Echelon60 EC60 stapler (3 rows of staples) was used. All further operational steps were identical for both groups. Target parameters were the postoperative anastomotic leakage and anastomotic bleeding rates.Between July 2004 and December 2005, the number of anastomotic leaks (Stapler Endopath, TSB 45) was n = 4 (2.7 %), for the second period (Stapler Echelon60 EC60), it was n = 9 (3.7 %) (not significant). Using the Endopath TSB 45 stapler, the number of anastomotic bleedings was n = 12 (8.1 %), and for the Echelon60 EC60 stapler, it was n = 8 (3.7 %) (p = 0.074; not significant). Within the 18-month period between July 2006 and December 2007, the number of endoscopic colon operations (n = 214) rose by 44.6 % compared to the 18-month period between July 2004 and December 2005 (n = 148).The application of the advanced Echelon endostapler has no impact on the number of anastomotic leaks, and reduces the number of anastomotic bleedings slightly but not significantly. The increased number of endoscopic procedures in the second period results both from the growing number of indications for the application of endoscopic techniques and the positive findings of recent studies carried out by our own and other working groups.